b'UnitedHealthcare Choice Plus PPO Blue Cross Blue Shield HMO Illinois (HMOI)BEHAVIORAL HEALTH SERVICES BEHAVIORAL HEALTH SERVICESInpatient Inpatient80%PPO after deductible $200deductible each hospital admission 50%Non-PPO after deductible(not to exceed 2 copays per year) Prior authorization requiredOutpatient100%PPO, deductible does not apply Outpatient50%Non-PPO provider after deductibleANNUAL PRESCRIPTION DRUG DEDUCTIBLE $30CopayAll care coordinated through your PCPTiers 1 & 2 No deductibleTiers 3 & 4 Annual Retail & Mail Order CombinedDeductible of $250 per individual not to PRESCRIPTION DRUG BENEFITS* exceed $500 for the entire family. Retail up to 30-Day SupplyPRESCRIPTION DRUG BENEFITS*$10Generic copayRetail up to 30-Day Supply$30Formulary brand copay $50 Non-formulary brand copay $0 Tier 1 copayRetail up to 90-Day Supply$50 Tier 2 copay$100 Tier 3 copay$25 Generic copay$250Tier 4 copay $75 Formulary Brand copayRetail up to 90-Day SupplyNot offered $125 Non-formulary brand copayMail Order up to 90-Day Supply Mail Order up to 90-Day Supply$0 Tier 1 copay $25 Generic copay $125Tier 2 copay $75 Formulary brand copay $250Tier 3 copay$125 Non-formulary brand copay $625Tier 4 copay* Specialty medications limited * Specialty medications limited to an up 30-day supply to an up to 30-day supply*Prescription Drug Plan ChangesEach health insurance plan utilizes a formulary (a list of preferred prescription drugs). INFO Formularies may change annually, so make sure you review your plans 2024formulary to determine if your prescription expenses will change. 18 CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 NON-MEDICARE HEALTH INSURANCE HANDBOOK'